RU2691437C1 - Method for surgical obliteration of left atrial appendage in patients with atrial fibrillation in operation on mitral valve or mitral valve and operation "labyrinth" in conditions of artificial circulation - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to cardiosurgery, and can be used in mitral valve or mitral valve operation and Labyrinth operation. Substance of the proposed invention is expressed in a set of essential features, according to which median sternotomy, longitudinal T-shaped pericardiotomy, main canisters are isolated for cannulation, artificial blood circulation is combined with hypothermia background 32–34 °C, ascending aorta and hollow veins are clamped, cardioplegia is performed. After performing the surgical stage on the mitral valve or on the mitral valve and the Labyrinth operation, the left atrial appendage (LAA) and tab obliteration, for which tip of eye LAA is turned through entire length into cavity LA and fixed to its base with U-shaped seam on gasket, ring base is closed with continuous two-row suture. Cardiotomy incisions are sutured. Chambers of heart are filled with blood. Cardiac activity is restored and haemodynamics is stabilized.EFFECT: eliminating the risk of developing cardiac thromboembolic postoperative complications arising from the presence of the increased LAA as the most thrombogenic zone LA.1 cl, 3 ex

Description

The invention relates to medicine, namely to cardiac surgery, and can be used during surgery on the mitral valve or on the mitral valve and operation "Labyrinth".

The process of remodeling of the heart with mitral defects causes an organic change in the left atrium (LP) with an increase in its size and, as a consequence, a decrease in its contractility and the appearance of new arrhythmia foci. In atrial fibrillation (AF), the left atrial appendage (AFL) increases along with the left atrium. Reducing the contractility of the LP and ULP leads to a decrease in the rate of intraatrial blood flow and blood stasis, thereby increasing the risk of a blood clot forming in the cavity of the ULP and the occurrence of systemic embolism. Approximately 90% of blood clots in the cavity of the PL are formed in his ear (Blackshear JL, Odell JA). Ann. Thorac. Surg. 1996; 61: 755-759; Granger V., Alexander JH McMurray JJV et al., Apixaban versus warfarin in patients with atrial fibrillation (The New England Journal of Medicine. 2011; 365; 11: 981-992). Mitral valve malformations (MK) in most cases are complicated by AF, and isolation of ULP will allow to avoid cardiogenic thromboembolic complications in the late postoperative period.

The known method of isolating SFM (Bockeria LA, Bockeria OL, Biniashvili MB, Donakanyan SA, Mironenko M.Yu., Ispiryan A.Yu., Klimchuk I.Ya. Simplified technique of ear bandaging of the left atrium in high-risk patients. Abstracts of the XX All-Russian Congress of Cardiovascular Surgeons. November 26, 2014) which consists in bandaging it with a dacron thread outside. At the base of the ear is installed vascular clamp, under which lavsan ligature is held. Tightening the node on the ligature is performed simultaneously with the opening of the clamp and the definition of a safe zone in the base region, away from the circumflex branch of the left coronary artery. When the ear is ligated, its ischemia, obliteration and subsequent scarring occur, which reduces its arrhythmogenic effect. The disadvantages are the eruption of atrial myocardium and epicardial fat of the altered wall of the enlarged ear, which often requires the imposition of additional stitches on the base of the ear after the restoration of cardiac activity on the background of parallel artificial blood circulation, which is a technically difficult maneuver. In addition, there remains a fairly pronounced cavity of the stump with elements of trabecularity, which is the site of the formation of blood clots and the source of embolic complications.

There is a known method of ligating the SFM using an automatic surgical stapler (DiSesa VJ, Tarn S., Cohn LH) atrial appendage using an automatic surgical stapler. Ann. Thorac. Surg. 1988; 46: 652-3) equipped with a fastening head with staples (brace length 4.8 cm) in stainless steel mounted on a rotating ball joint. The rotating head allows you to accurately match the line for stitching the base of the LAA. The disadvantages are the high injury during the operation and the high cost of the operation.

The known method using the clip "LP-Epiclip" to isolate the left atrial appendage (RU # 2641063, 2017) containing a lock in the form of a dacron thread placed in loops pressed into the ends of the working parts, with a jumper in the form of a spring pressed into the tube, with This working parts and lintel provided with a coating in the form of a knitted tube, woven of polyester yarn. During the operation, the LAA is carefully captured using the Babcock clamp and retracts medially. The ear of the left atrium is placed between the working parts of the clip, providing reliable and atraumatic isolation of the ear, with a force given by the spring. Then the free ends of mylar filament are tightened and tied together by a surgical unit. The disadvantage is the frequent presence of residual stump at the base of the ULP more than 1 cm long, which implies additional problems further in the treatment.

There is a method of resection of AFM, including excision of it with scissors or electrocautery, followed by closure of the stump from the epicardium with a double polypropylene suture 4-0. This method takes less than 5 minutes, the suture zone is checked for hemostasis, it is fast and inexpensive. The disadvantage of this method is bleeding from the suture line due to the modified wall of the LAA (Left atrial appendage occlusion: lessons. Ann. Thorac. Surg. 2011; 92 (6): 2283-92).

The prototype of the proposed method is a method of surgical reduction of the LP cavity with suturing of ULP (RU # 2348364, 07/17/2007), which consists in creating a blanket continuous seam of the lower back wall of the PL from the upper edge of the interatrial septum incision to the ULP base to the upper edge incision of the roof of the atrium. The disadvantages of the operation are, firstly, the technical complexity of its implementation and, consequently, an increase in the time of extracorporeal circulation (IC), secondly, there is a high risk of inconsistency of the seams and the occurrence of recanalization with the formation of the atrial-ear fistula, and as a result enter the cavity of the LP and then spread in the form of emboli, which creates the risk of thromboembolic events.

The present invention is directed to solving a technical problem, which consists in creating a method of obliteration of the most arrhythmogenic and thrombogenic zone of the LP, increasing the effectiveness of treatment and prevention of cardiogenic thrombosis and thromboembolism in patients with AF with simultaneous correction of MK pathology or pathology of MK and operation "Labyrinth".

The technical result of the invention is the elimination of the risk of developing cardiogenic thromboembolic complications in the postoperative period, arising due to the presence of ULP as the most thrombogenic zone of the LP, by reducing the risk:

- formations of the atrial fistula or residual cavity of the LDP;

- bleeding from the suture line as a result of the eruption of the thread into the pericardial cavity.

The essence of the invention is expressed in the combination of essential features, according to which perform median sternotomy, longitudinal T-shaped pericardiotomy, isolated main vessels for cannulation, connect the IR. Artificial blood circulation is connected against the background of hypothermia 32-34 ° C, pinching the ascending aorta and the vena cava, carry out cardioplegia. After completing the operation stage on the mitral valve or on the mitral valve and the operation “Labyrinth”, access the left atrial eye and the ear obliteration is performed, for which the top of the ULP is inverted to its base by the U-shaped seam on the pad , the base of the eyelet is sutured with a continuous two-row suture. Cardiotomic incisions are sutured. The chambers of the heart are filled with blood. Restore heart activity and stabilize hemodynamics.

The method is as follows.

Median sternotomy, longitudinal T-shaped pericardiotomy are performed, trunk vessels for cannulation are isolated, IC is connected against hypothermia 32-34 ° C, ascending aorta and vena cava are clamped, cardioplegia is performed, access to the MC by resection of the right atrial appendage is performed, dissection of the Lp dome and WFP. The next step is prosthetics or plastic MK, or operation on the mitral valve and the operation "Labyrinth". After that, the ear is obliterated. The top of the ULP is turned over the entire length into the cavity of the LP, the tip of the ULP is fixed to its base with a 3-0 U-shaped polypropylene suture on a PTFE gasket, then the ear base is sutured with a continuous two-row polypropylene 3-0 suture. After suturing the cardiotomic incisions and filling the chambers of the heart with blood, restoring cardiac activity and stabilizing hemodynamics, an EAPC is performed intraoperatively to confirm obliteration of ULP and the absence of additional doppler signals in the cavity of ULP, indicating the absence of recanalization and eruption of the sutures.

Example 1

Patient A., 61 years of age, was diagnosed with calcified aortic valve disease - critical stenosis, on the basis of an objective examination, anamnesis of the disease, transthoracic ultrasound examination and ERE. Stenosis and insufficiency of the mitral valve. Thrombosis of PL and SFM. The permanent form of the OP.

Median sternotomy was performed, longitudinal T-shaped pericardiotomy, IR connected with 32-34 ° C hypothermia, cardioplegia performed. Access to the MC was carried out by resection of the right atrial appendage, dissection of the LP and MPP domes. A revision of the LP and SFM was carried out: in the SFM, a near-wall organized thrombus was detected, tightly soldered to the epicardium, calcined in places, measuring 2 × 3 cm. The thrombus was removed from the AFM by a blunt and sharp way. The operation of the prosthetic mitral valve, prosthetic aortic valve. The next step is obliterated by the LAA of the proposed method. The top of the ULP was turned out to the full length of the LP cavity and fixed to its base with a 3-0 U-shaped polypropylene suture on a PTFE gasket, the base of the ear was sutured with a continuous two-row polypropylene suture 3-0. After suturing the cardiotomic incisions and filling the heart’s chambers with blood, restoring cardiac activity and stabilizing hemodynamics, an EAP was performed intraoperatively to confirm obliteration of ULP and the absence of additional doppler signals in the cavity of ULP, indicating the absence of recanalization and eruption of the sutures.

Postoperative bleeding and cardiogenic thromboembolic complications were not observed. Before discharge of the patient from the hospital, a CPEH was performed, which showed the absence of Doppler signals in the ULP, indicating the absence of atrial-ear fistula and the eruption of the sutures.

Example 2

Patient G., 15 years of age, was diagnosed with CHD due to ultrasound examination of the heart and computed tomography (the normal variant of the pulmonary veins falling into the LP, the absence of defects in the distribution of the contrast medium in the abdominal cavity). Myxomatosis of the mitral and tricuspid valves. Insufficiency MK. Relative failure of the tricuspid valve. Dilatation LP. Marfan syndrome.

Median sternotomy was performed, longitudinal T-shaped pericardiotomy, IR connected with 32-34 ° C hypothermia, cardioplegia performed.

Access to the MC was carried out by resection of the right atrial appendage, dissection of the LP and MPP domes. The operation of multicomponent reconstruction of the MC; plastic tricuspid valve. During the audit of LP and SFM blood clots were not detected. Further, the proposed method is obliterated with LAA. The top of the ULP was turned over the entire length into the LP cavity and fixed to its base with a 3-0 U-shaped polypropylene suture on a PTFE gasket, then the eyelet base was sewn with a continuous two-row polypropylene suture 3-0. Closure of cardiotomic incisions, filling of the heart chambers with blood, restoration of cardiac activity and stabilization of hemodynamics. A CPEchoCG was performed intraoperatively: the plastic of the atrioventricular valves is consistent, there are no additional Doppler signals registered in the ULP.

Postoperative bleeding and cardiogenic thromboembolic complications were not observed. Before discharge of the patient from the hospital, a CPEH was performed, which showed the absence of Doppler signals in the ULP, indicating the absence of atrial-ear fistula and the eruption of the sutures.

Example 3

Patient K., 66 years old, was diagnosed based on ultrasound examination of the heart and Holter monitoring of electrocardiography for 24 hours (basic sinus rhythm, short episodes of AF): mitral valve defect (insufficiency). Paroxysmal form of OP.

Median sternotomy, longitudinal T-shaped pericardiotomy, IR connected with hypothermia 32–34 ° C, cardioplegia performed.

Access to the MC was carried out by resection of the right atrial appendage, dissection of the LP and MPP domes.

RFA effect was performed with isolation of the lower isthmus, isolation of the mouths of the pulmonary veins at the site and in the area of the fibrous ring MK. Made plastic MK. The ear of the left atrium is sutured from the inside by the proposed method. The top of the ULP was turned out to its full length into the cavity of the PL and fixed to its base with a 3-0 U-shaped polypropylene suture on a PTFE gasket, the base of the ear was sewed with a continuous two-row polypropylene suture 3-0. Closure of cardiotomic incisions, filling of the heart chambers with blood, restoration of cardiac activity and stabilization of hemodynamics. The ITPEKG was performed intraoperatively: the plastic of the MK is well-established, there are no additional Doppler signals registered in the ULP.

Postoperative bleeding and cardiogenic thromboembolic complications were not observed. Before discharge of the patient from the hospital, a CPEH was performed, which showed the absence of Doppler signals in the ULP, indicating the absence of atrial-ear fistula and the eruption of the sutures. At discharge, the patient was recorded sinus rhythm.

The proposed method in patients with chronic and paroxysmal AF after the main stage of the operation on the mitral valve or on the mitral valve and the operation "Labyrinth" in various modifications due to the inversion of the top of the ULP in its full length in the LP cavity and fixing the top of the ULP to its base P a seam on the gasket allows you to radically remove the thrombogenic zone of the LP, thereby reducing the risk of thromboembolic complications in the postoperative period, as well as reducing the risk of bleeding from the suture line as a result of stitching threads into the pericardial cavity, due to the suturing of the base of the ear with a continuous two-row suture.

Claims (1)

Method surgical obliteration of left atrial appendage in patients with atrial fibrillation at operation on the mitral valve or the mitral valve and the operation "Labyrinth" cardiopulmonary bypass, comprising executing median sternotomy, longitudinal T-pericardiotomy, selection of great vessels for cannulation, connecting cardiopulmonary bypass , characterized in that the artificial blood circulation is connected against the background of hypothermia 32-34 ° C, pinch the ascending aorta and the vena cava, carry out after performing a stage of operation on the mitral valve or on the mitral valve and operation “Labyrinth”, access the ear of the left atrium and the obliteration of the ear, for which the tip of the left atrium is inverted into the cavity of the left atrium and fixed to its base. -shaped seam on the gasket, sutured the base of the ear with a continuous double-row suture, sutured cardiotomic incisions, fill the heart chambers with blood, restore cardiac activity and hemodynamic stabilization.